Supraneural versus Infraneural Approach to transforaMinal Epidural StEroid injection for unilateral lumbosacral radicular pain (SIAMESE): a study protocol for a randomised non-inferiority trial

Abstract

Background: Lumbosacral radicular pain is commonly treated by transforaminal steroid epidural injection. There are two methods: the supraneural and the infraneural approaches. The supraneural approach can result in rare but catastrophic consequences from injury to the radiculomedullary artery. The infraneural technique avoids the artery; both approaches show efficacy and are used locally. Methods: This is a protocol for a randomised, single-blinded, non-inferiority trial of infraneural vs supraneural transforaminal epidural injection for lumbosacral radicular pain at a tertiary referral pain management clinic. Adult patients (n=92) with moderate-to-severe lumbosacral radicular pain of >3 months duration, scheduled for transforaminal epidural steroid injection, will be randomised to epidural by either the infraneural or supraneural approach. Only the treating physicians will know which route is used. The primary outcome measure is the differential impact on pain intensity score at 3 months. Secondary outcome measures will include disability and function scores, sleep and activity measures, and adverse events. Participants will be followed up for 12 months. Conclusions: This study will determine whether the techniques are comparable and, if so, will enable recommendations for the use of an approach without risk of artery damage and catastrophic injury. Clinical trial registration: ISRCTN 36195887.

Keywords

• epidural
• lumbosacral radicular pain
• non-inferiority
• randomised controlled trial
• steroid